Kathy Wire LeadingAge Missouri September 2, 2015 1

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PSO: Your Partner in the New Frontier

Kathy WireLeadingAge MissouriSeptember 2, 2015

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What Problems Did the Act Address?

• Fear of using information against provider

• Inconsistent State protections for safety analyses

• Inability to aggregate data to improve patterns of care & reduce system failures across providers

Copyright © 2015 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be reproduced without consent of the Center for Patient Safety.

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Federal Protections: 42 U.S.C. §1395i

• Develop and implement appropriate plans of action to correct identified quality deficiencies.

• “A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements [of the law].”

– Professional liability vs. regulatory or criminal?

• Few courts have interpreted the privilege, and they have had different results. All indicate it must be narrowly construed.

• MO (State ex rel. Boone Retirement Center, Inc. v. Hamilton): Only protects documents created by the committee, not information submitted to it

• Ohio: In civil cases, issue controlled by state law (Bailey v. Manor Care of Mayfield Hts., 2013-Ohio-4927.)


4Copyright © 2015 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be reproduced without consent of the Center for Patient Safety.

MO Peer Review Statute: R.S.Mo §537.035

• Applies to skilled nursing homes and assisted living • Protects a broad range of information generated by a

“committee of health care professionals.”– RN and LPN– Physician– Not RD, CDM, CNA, resident, family, etc.

• Under recent case, may not apply to information provided to (not generated by) the committee, e.g. expert report

• Information can be subpoenaed by licensing boards• Can be waived

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Attorney-Client Privilege; Work Product


Fancher v. Shields, et al., No. 10-CI-4219, Jefferson Circuit Court (KY 8/16/2011)

“[T] sentinel event and root cause analysis information was not prepared for the purpose of facilitating the rendition of legal services…It was not intended to be solely entrusted to the confidence of the…attorney, but was for other business purposes.”“This information was not prepared in anticipation of litigation, but …to comply with the hospital’s (JC) reporting requirements. …..

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Intent of the PSQIA

• A safe environment supporting reporting, sharing, and learning about medical errors

• Proactive prevention of medical errors & patient harm

• Reduction of healthcare costs from error & patient harm


PATIENT SAFETY ORGANIZATIONS (PSOs)

To be certified, a PSO must demonstrate:• Ability to securely and confidentially collect, analyze and

report adverse events

• Required policies and procedures in place

• Staff meets qualifications

• Performs Patient Safety Activities

• Ability to work with any healthcare provider licensed by a state

• Provide PSO-related federal confidentiality and legal protections

More information: http://www.pso.ahrq.gov/index.htmCopyright © 2015 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be reproduced without consent of the Center for Patient Safety.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&docid=PBG8ytiLo1H6AM&tbnid=bBwxUaveQuy1fM:&ved=0CAUQjRw&url=http://axialexchange.com/blog/article/an-overview-of-the-ahrq-patient-engagement-guide&ei=lXcvUvHXJKeZ2QWSlYCADg&bvm=bv.51773540,d.b2I&psig=AFQjCNETNgHn7jkbGqXkriEV7HO3Ha6Ryg&ust=1378928909168853

HOW CAN THE PSQIA AND PSOs IMPROVE SAFETY?

Aggregate data from many providers Providers can confidentially report medical errors, near misses and unsafe conditions with federal legal protection from disclosure

Providers to work together in a confidential, protected space to share and learn how to prevent mistakes and improve quality and outcomes of careProviders can be open about safety issues and concerns without fear of their safety work being held against them.


PSOs – Part of the Solution

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PSOs Support Transparency

• Broader internal discussions– Subject matter: looking back and

forward– Pool of participants not limited

• External sharing• PSO’s can support working

among multiple providers• Center Whitepaper, “PSOs and

Transparency: Working Together to Improve Patient Safety”

www.centerforpatientsafety.org/publications/

http://www.centerforpatientsafety.org/publications/


PSOs Support ACO/Collaborative Goals

• ACOs and other bundling require providers across care settings to– integrate care– ensure the safety, quality and

health of the population– share in cost and cost savings

• Collaboratively address concerns that affect success for all

• LTC must be able to work together AND demonstrate its own effectiveness

• Center Whitepaper, “PSOs Essential to ACO Success”

www.centerforpatientsafety.org/publications/



• Work across multiple providers– Identify vulnerabilities that could raise costs or reduce quality – Learn about adverse events and unsafe conditions that exist across

participating providers and how they interact– Analyze errors and safety concerns across the ACO– Confidential environment to address improvement

• Confidential space for the aggregation and sharing of data • Flexibility of PSO programs to serve various coordinated care

models• PSO support tools for investigations, e.g. RCA tool• Broad definition of safety, within the context of PSO

participation, encompasses quality and patient experience measures, as well as population health work

Benefits of PSO Participation for ACOs*

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Key Provisions - Processes

Pt/ Resident Safety Activities

Patient Safety Evaluation System (PSES)

Patient Safety Work Product (PSWP)

Protection of quality and

safety discussions

and documents

Protection for processes


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Patient Safety Evaluation System (PSES)

• “The collection, management, or analysis of information for reporting to or by a PSO”

• The mechanism by which information can be collected, maintained, analyzed and communicated

• PSES exists when:– a provider engages in patient safety

activities for the purpose of reporting to a PSO

– a PSO engages in patient safety activities


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Patient Safety Work Product (PSWP)

Data, reports, records, memoranda, analyses, or written or oral statements which

• are assembled or developed by a provider for reporting to a PSO and are reported to a PSO, or• are developed by a PSO for the

conduct of patient safety activities, or• which identify or constitute the

deliberations or analysis of, or identify the fact of reporting pursuant to, a PSES


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QAPI: Improvement at the Organizational Level

General Information and Resources:www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html

• “…a data-driven, proactive approach to improving the quality of life, care, and services in nursing homes.”

• Involve members at all levels of the organization, multiple departments, residents and families

• Identify opportunities for improvement• Address gaps in systems or processes• Develop and implement an improvement or plan• Continuously monitor the effectiveness of interventions


http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/NHQAPI.html

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What you might want to protect: QAPI

• “Identify your gaps and opportunities” (.p. 16)

• “Prioritize your opportunities for more intensive improvement work” (p. 16)

• “Determine what information you need for your PIP” (p. 17)

• Measure and report on results• Observations • Research used to develop changes• Assessments of your QAPI process in

general

References are to “QAPI at a Glance”


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QA and PI—facility level

• Incident reports• Logs (falls, weight,

wounds, etc.• Interdisciplinary teams

(fall team, skin team, NAR, etc.)

• Daily meeting discussion

• Surveys of staff, residents

• QAPI oversight team• PIP teams

Committee,Team

minutes

Survey on Resident

Safety Reports

Reports of near miss, concerns

Root cause analysis,

FMEA

QAPI oversight and PIP team D and A

Reports on resident incidents


Data on outcomes and issues

for joint pt/

residents

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QA and PI—corporate or system level

• Events reported, near miss or safety concerns

• Roll-up or comparative data and trends

• Teams that work on corporate-wide initiatives

• Surveys of staff, residents

• QAPI oversight team• PIP teams

Minutes, reports of

committees

Survey on Resident

Safety Reports


Root cause analysis, FMEA of shared issues

QAPI oversight and PIP

team records; D and A


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QA and PI—collaborative care setting

• Events reported, near miss or safety concerns

• Data on outcomes, trends

• Teams that work on collaborative-wide initiatives

Trend reports developed

for oversight of safety and

quality

Discussion of

common issues on

SOPS


Root cause analysis, FMEA of shared issues

Collect issues to

bring back for QAPI in

facility


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The “Social Contract”

• PSO’s pledge to..– provide a safe environment in which to report and discuss

adverse events, and– share the learning obtained from the reporting

• Healthcare providers pledge to..– report complete and accurate information about adverse

events, near misses and unsafe conditions to the PSO to feed the learning

• Together, Healthcare providers and PSO’s pledge to focus efforts collectively on improving the safety of care for all patients


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How to Get Started

• Contract with PSO

• Develop and abide by policies– Define PSES, PSWP, PSES

Workgroup and Workforce

• Educate appropriate staff

• Submit data/information to PSO

• Begin PSO discussion with collaborative providers


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Multi-Provider Collaboration:

• Easiest when all providers are part of common system and it is participant in PSO

• Also easy when providers are all part of same PSO– CPS has 116 hospital participants in MO– CPS has 140 EMS participants in MO

• Possible but more challenging when providers participate with different PSO’s

• Team(s) to work on common issues that affect success of the collaborative endeavor

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Challenges and Opportunities


• Other Initiatives—PSO can be integrated• Surveyors—CMS may resolve issue ??????

– Cannot disclose PSWP– Work with state agency to develop ground rules– They can confirm process; content is confidential

• Multiple provider: ACO, regional• Integrating with other privileges

– Attorney-client– State QA/Peer review

25Copyright © 2015 Center for Patient Safety. All rights reserved. All or any part of this presentation may not be reproduced without consent of the Center for Patient Safety.

What you might want to have available –or can’t protect

Possible info for surveyors or others with an interest:

• PIP team charters• Event reports—basic and factual• Logs• Actual steps taken to improve: new policies, education for

staff, etc.• Data to establish the results of QAPI projects, preferably from

QI/Oscar reports or logs they will see anyway

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Questions?

Kathryn Wire, JD, MBA, CPHRMCenter for Patient Safety

www.centerforpatientsafety.org888-935-8272314.540.4910

[email protected]


http://www.centerforpatientsafety.org/

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Kathy Wire LeadingAge Missouri September 2, 2015 1